Healthcare Provider Details

I. General information

NPI: 1306634654
Provider Name (Legal Business Name): OPAL PSYCHOLOGICAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 BROOKE CT UNIT 1405
SAN DIEGO CA
92122-5362
US

IV. Provider business mailing address

1111 6TH AVE STE 550 #292745
SAN DIEGO CA
92101
US

V. Phone/Fax

Practice location:
  • Phone: 619-259-0107
  • Fax:
Mailing address:
  • Phone: 619-259-0107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name: LADERA NICOLE PEREZ LINN
Title or Position: PRESIDENT
Credential: PSYD
Phone: 619-259-0107